AND ANSWERS A+ GRADED
subjective data vs objective data
subjective is what the client tells you whereas objective is what the RN observes
subjective - symptoms (what the patient feels, information gathered from the patient)
objective - signs (information gathered from physical exams and lab tests, factual and
descriptive, professional findings)
what is oldcart?
O nset (where sign/symptom began)
L ocation (where sign/symptom is located)
D uration (how long it's been going on)
C haracteristics (what it feels like, how it is described, severity)
A ssociated manifestations (what else is going on when experiencing sign/symptom)
R elieving factors (anything the patient has tried to relieve their sign/symptom)
T reatment (any interventions; ie, going to a specialist)
what is the nursing process?
ADPIE
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A ssessment
D iagnosis
P lanning
I mplementation
E valuation
what is a cluster of information?
information that is gathered and put together to localize main area of pain (chief
complaint); it furthers your clinical reasoning to make appropriate decisions
nursing diagnosis vs medical diagnosis
nursing diagnosis: focus on patient's physical and psychological response & identify
potential problems
, medical diagnosis: focuses on actual disease process/illness of the patient
*both use physical assessment, interviewing and observing as ways to derive the
diagnosis
*both are designed for planning patient care
define heent in the review of systems
HEENT
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H ead
E yes
E ars
N ose
T hroat
what is PERRLA?
P upils are
E qual
R ound
R eactive to
L ight and
A ccommodation
what is EOM?
E xtra
O cular
M ovement
what is TM?
T ympanic
M embrane
what is JVP?
J ugular
V enous
P ressure
what is RCM?